Medi-Cal Update

Pharmacy | July 2017 | Bulletin 899

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2. CCS Service Code Groupings Update

The following codes will be end-dated from the California Children's Services (CCS) Service Code Groupings (SCGs).

End-Dated Codes:

Effective Date Code SCGs
November 1, 2016 HCPCS codes X4506, X4508, X4510, X4536, X4538 02, 03, 04, 05, 06
November 1, 2016 HCPCS codes X4512, X4514, X4516, X4518, X4524, X4528, X4546 04, 05
November 1, 2016 HCPCS code Z0316 01, 02, 03, 04, 05, 06, 07
November 1, 2016 HCPCS code Z5926 02, 03, 04, 05

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Clinics and Hospitals
Chronic Dialysis Clinics
Durable Medical Equipment
Community-Based Services
General Medicine
Home Health Agencies/Home and Inpatient Services
Local Educational Agency
Medical Transportation
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (1–3, 5–20, 23–29, 31)
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3. 2017 HCPCS Update for Physician Administered Drugs

Effective for dates of service on or after April 1, 2017, the following HCPCS codes are Medi-Cal benefits and are reimbursable when performed by a non-physician medical practitioner (NMP):

HCPCS Codes Description
C9484 Injection, eteplirsen, 10 mg
C9485 Injection, olaratumab, 10 mg
C9486 Injection, granisetron extended release, 0.1 mg
C9487 Ustekinumab, for intravenous injection, 1 mg
C9488 Injection, conivaptan hydrochloride, 1 mg

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
inject cd list (4, 6, 7, 12, 16); inject drug a-d (21, 22); inject drug e-h (15, 16, 24, 25); inject drug n-r (2, 3); inject drug s-z (15, 16)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (4, 6, 7, 12, 16); inject drug a-d (21, 22); inject drug e-h (15, 16, 24, 25); inject drug n-r (2, 3); inject drug s-z (15, 16); non ph (10, 22)
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4. Product Descriptions Updated for Incontinence and Creams and Washes Products

Smart Choice Medical Inc. has changed product descriptions for two underpads and two creams. The product descriptions have been updated on the List of Contracted Incontinence Creams and Washes and on the List of Contracted Incontinence Absorbent Products.

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5. Face-to-Face Encounter Required for DME Prescription

Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to allow reimbursement to providers only for Durable Medical Equipment (DME) items that are signed for by a physician in either written or electronic format. Additionally, a face-to-face encounter administered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, related to the primary reason the recipient requires the DME item, is also required. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (1, 4, 5); dura bil dme (3, 9, 10, 14, 22, 25); dura bil oxy (12); dura bil thp (11)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (3, 12)
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6. National Correct Coding Initiative Quarterly Update for July 2017

The Centers for Medicare & Medicaid Services has released the quarterly National Correct Coding Initiative payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are valid for dates of service on or after July 1, 2017.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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7. Lanreotide Policy Expansion to Include GEP-NETs

Effective for dates of service on or after August 1, 2017, coverage for HCPCS code J1930 (injection, lanreotide, 1 mg) has been expanded to include treatment of patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs). The dosage recommendations have also been expanded to include more specific instructions for treatment of patients with either GEP-NETs or acromegaly. The list of ICD-10-CM diagnosis codes required for authorization has also been expanded. An approved Treatment Authorization Request (TAR) is also required for reimbursement.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject drug i-m (9, 10)
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8. Reminder: Avoid Printing Data in Margins of Paper Claim Forms

In order to ensure timely and accurate claims processing, providers are reminded to avoid printing data in the margin, header or footer portion of paper claim forms. Overlapping data may be misread. For example, processing has been delayed for certain claims with address information typed in the header portion of the CMS-1500 claim form.

The Billing Tips: Paper Claims page of the Medi-Cal website has been updated to reflect the above and to align with a previously published NewsFlash article titled “Reminder: Paper Claim Submission Guidelines.” For more general reminders about paper claim submission, please visit the page or call the Telephone Service Center (TSC) at 1-800-541-5555.

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9. August 2017 Medi-Cal Provider Seminar

The August Medi-Cal provider seminar is scheduled for August 15 – 16, 2017, at the Sacramento Marriott in Sacramento, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, Department of Health Care Services (DHCS) and Conduent, the Fiscal Intermediary for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by August 1, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After August 1, 2017, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks Web page on the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers who require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative Web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.

Providers are encouraged to bookmark the Provider Training Web page and refer to it often for current seminar information.

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